Certified RN Case Manager with over 25 years of successful experience in Case Management, Medicare/Medicaid Managed Care and Managed Care. Recognized consistently for performance excellence and contributions to success within the Managed Care industry.
Skills
Multidisciplinary team collaboration
Staff Management and Training
Team Building
Project oversight
Care management
MS Office - Excel, PowerPoint, Word, Visio
Medicare, Medicaid and Commercial Insurance Utilization Management
Accomplishments
Case Management Society of America - Birmingham Chapter 2008-2010 Board of Directors
Case Management Society - Birmingham President 2011
UHG SAGES clinical excellence nominee 2010, 2012 and 2015
UHG MCG Governance Committee
Work History
Regional Director of Care Management , 10/2016 - 10/2019 Catholic Health Initiative – Tacoma, WA,
Development, implementation, execution and monitoring of care management services for the National Post Acute Care Clinical Services team.
Provided guidance leadership to 125+ remote employees across 4 regional teams.
Developed and updated policies and procedures, maintaining compliance with statutory, regulatory and local, state and federal guidelines relating to HIPAA, benefits administration and general liability.
Subject matter expert lead for cross functional workgroups, new contract implementation, clinical system installations, workflow process improvements, FTE allocation, MCG focused review process, CMS/Medicaid/Health Plan audits
Manager Case Manager - Southeast Region, 10/2007 - 10/2016 UnitedHealth Group – City, STATE,
Oversight SE region onsite and telephonic utilization review and case management to MAPD members transitioning between various levels of care.
Implemented and expanded onsite UM program in AL, GA, FL, NC, NY, NJ market in targeted Acute Inpatient Rehab and Skilled Nursing Facility.
MAPD/Medicaid/ISNP UM program with 28 Onsite RN Care Managers/50+ Telephonic Care Managers
Streamlined CM procedures and UM tasks by implementing new workflow processes and maximizing computer based solutions.
Liaised with sales, marketing and management teams to develop solutions and accomplish shared objectives within clinical services and enterprise.
Collaborated cross-functionally with headquarters, regional and other teams nationally to maintain consistent message and experience.
Collaborated with upper management to implement continuous improvements and exceed team goals.
Developed compelling presentation decks to gain approval for ideas and communicate results.
Investigated and integrated new strategies to expand business operations and grow onsite post acute care management program
Achieved established KPI for company, regional team and individual performance through teamwork and focus on customers.
Streamlined CM procedures and UM tasks by implementing new workflow processes and maximizing computer based solutions.
Onsite RN Care Manager - Post Acute Care, 02/2007 - 10/2009 UnitedHealth Group – City, STATE,
Onsite Care Management responsible for utilization and case management for members transitioning from the acute care setting to all post acute levels of care.
Managed 50-75 member caseload. Audited charts, reviewed clinical documents to verify accuracy
Utilized CMS guidelines to ensure appropriate post acute level of care
Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
Educated patients and caregivers on diagnosis, prognosis, treatment options, disease process management
Collaborated with internal and external interdisciplinary healthcare personnel to meet patients' personal, physical, psychological and cognitive needs.
Bedside visits with members, families and attendance at weekly IDT meetings
RN Care Manager, 04/2005 - 08/2007 University Of Alabama At Birmingham Hospital – City, STATE,
Case Manager for Trauma/Burns, ENT/Plastics and cross covered for Cardiology/General Surgery and Ortho/Neuro
Conferred with physicians to discuss diagnoses and devise well-coordinated treatment approaches.
Evaluated healthcare needs, goals for treatment and available resources of each patient and connected to optimal providers and care.
Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
Audited charts and reviewed clinical documents to verify accuracy.
Applied InterQual guide lines utilizing McKesson portal to obtain initial approval and continued stay
Collaborated with interdisciplinary healthcare personnel to meet patients' personal, physical, psychological and cognitive needs.
Education
Bachelor of Science: Nursing, Expected in 12/1993 - University Of Alabama At Birmingham - Birmingham, AL GPA:
Affiliations
Case Management Society of America - 1998 to present
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